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2 Disclosures Dr. Williamson is an employee of Janssen Scientific Affairs, LLC. No statements made during this presentation relate to Janssen products, and none should be interpreted to represent the views of Janssen Scientific Affairs, LLC. The content and opinions expressed in this presentation are solely those of the presenters and not necessarily those of Janssen Scientific Affairs, LLC.

3 First Case of the Morning Dr. Reese is a 61-year old cardiologist. His family is concerned about some recent forgetfulness, errors in judgment, and subtle changes in personality. Dr. Reese denies any problems or changes. His family doc finds no problems, and he scores normally on the MMSE. He knows that he is nearing retirement, his first grandchild has just been born, and the delivery was complicated...

4 First Case of the Morning His primary care doc feels that he s probably just under a lot of stress, if there s anything there at all. The family is not so sure, and they are concerned about both liability issues and what they ve heard about early intervention being important with many conditions causing mental status changes. The doc, a friend of yours, knows that you have an interest and some expertise in these issues, and refers to you for a second opinion. What can they do next?

5 Case #2 Ms. Smith is a 68-year old retired housekeeper with a 4 th -grade education whose family is concerned about her recent memory problems. She has a long history of periods of depression, only once needing to be hospitalized. She has been feeling more down in the dumps over the past couple of months. Labs come back essentially normal, MMSE = 23. How concerned should you be about the early stages of a dementing process?

14 Significant For What? Diagnosis Prediction of Function or Competency Driving Ability to make decisions Assessing Change over Time How much of a change is meaningful? How long should I wait between retests?

15 Source of Information Who is reporting the problem(s)? Patient Family / informant Performance on objective testing

17 Diagnosis The Role of Testing despite an understandable drive toward ultra-brief tests which can be used in a typically time-constrained general practitioner consultation, an administration time of more than 10 minutes appears to be an unavoidable cost of achieving sufficiently robust statistical performance while covering key domains. (pp 59-60) Lin et al 2013, AHRQ, Screening for Cognitive Impairment in Older Adults: An Evidence Update for the U.S. Preventive Task Force. Available at:

24 Diagnosis: Assessment of Change Published data are available to guide interpretation of changes seen in serial testing with MoCA 1 Other scales (e.g., ADAS-Cog, MMSE) available for assessment of change, depending on needs 1 Costa AS et al. (2014). Dement Geriatr Cogn Disord, 37(1-2),

25 When to Refer for Neuropsych +/- results in a bright patient, particularly in the presence of patient or family complaint Legal capacities are at issue but deficits are not yet striking Most capacities impaired at MMSE < 20 But potential educational confound Mild problems in someone with low education or language limitations

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